Provider Demographics
NPI:1437317583
Name:GAGGINI, SHELLEY A (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:A
Last Name:GAGGINI
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4250 S EASON BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6549
Mailing Address - Country:US
Mailing Address - Phone:662-377-6275
Mailing Address - Fax:662-377-6299
Practice Address - Street 1:4250 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6549
Practice Address - Country:US
Practice Address - Phone:662-377-6275
Practice Address - Fax:662-377-6299
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS710891133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03449OtherMEDICARE GROUP